CAMHS New Comprehensive Assessment

Other person/sources of information: Mother, Father, School Teacher Services involved: Social Services, School Counselling Protected characteristics: Diagnosed with ADHD, struggles with reading due to dyslexia. Child safeguarding: Child lives with both parents, who have parental responsibility. No current safeguarding concerns. Household composition: Lives with both parents and younger sister. History of Presenting Complaints: Patient presents with symptoms of low mood, irritability, and difficulty concentrating. These symptoms have been present for approximately 6 months, with a gradual onset. The patient reports feeling sad most days, experiencing a loss of interest in activities they previously enjoyed, such as playing video games and spending time with friends. They also report difficulty sleeping, with frequent awakenings during the night. The patient's appetite has decreased, and they have lost weight. The patient reports feeling overwhelmed by schoolwork and struggles to focus in class. They have also reported feeling hopeless about the future. The impact of the problem on day-to-day activities includes difficulty getting out of bed in the morning, reduced participation in school, and withdrawal from social activities. The patient's personal hygiene has been affected, with less attention paid to grooming. They are struggling to complete homework assignments and their grades have declined. They are also experiencing increased conflict with their parents. Associated symptoms include feelings of worthlessness, excessive guilt, and recurrent thoughts of death. The patient reports these thoughts occur several times a week and last for a few minutes each time. They have not made any plans to harm themselves. Precipitating Factors: Increased academic pressure, bullying at school, and recent arguments with parents. Perpetuating Factors: Social isolation, negative self-talk, and avoidance of schoolwork. Social History: Patient is currently attending secondary school and is struggling academically. They have a few close friends but have withdrawn from social activities recently. They live in a stable home environment with their parents and sister. They have limited access to financial resources. Personal history includes a history of being a happy and outgoing child. They enjoyed playing sports and spending time with friends. They have always had a close relationship with their parents. They have experienced bullying at school in the past. Patient is able to perform essential independent living skills, including personal care, eating/drinking, and household tasks. Past Medical & Psychiatric History: - Diagnosed with ADHD at age 8. - No prior psychiatric hospitalizations. - Chronic medical conditions: Asthma Child Development: Normal birth and developmental milestones. No complications during pregnancy or delivery. Forensic/Offending History: No reported forensic or offending history. Premorbid Personality: Patient was previously described as a happy, outgoing, and resilient child. They were able to form and maintain relationships and cope with stress. They enjoyed playing sports and spending time with friends. Medications: - Methylphenidate 10mg twice daily for ADHD. Family History: Mother has a history of depression. Father has a history of anxiety. Mental Status Examination: Appearance: Appears dishevelled, with unkempt hair and clothing. Appears their stated age. Behaviour: Restless and fidgety, with poor eye contact. Speech: Slowed speech, with a low volume and monotone tone. Mood: Patient reports feeling sad and hopeless. Affect: Restricted affect, with limited emotional expression. Thoughts: Reports feelings of worthlessness and recurrent thoughts of death. Perceptions: No hallucinations or sensory misinterpretations. Cognition: Oriented to time, place, and person. Memory intact. Concentration is impaired. Insight: Limited insight into their condition. Judgment: Judgment appears impaired. Risk Assessment: Risks to self: Reports recurrent thoughts of death, but denies suicidal ideation or plans. No current risk of self-harm. Self-harm: No reported self-harm risks. Risks to others: No reported risks to others. Substance use: No reported substance use concerns. Risks from others: No reported risks from others. Protective factors: Supportive family, previous positive coping strategies. Service User Views and Goals: Patient would like to feel happier, improve their mood, and improve their concentration in school. SMART Goal 1: Improve mood and reduce symptoms of depression within 8 weeks. SMART Goal 2: Improve concentration and academic performance within 12 weeks. Initial Formulation/Impression: Patient presents with a moderate depressive episode, likely triggered by academic pressure and bullying. The patient's ADHD and dyslexia may be contributing factors. The patient is at risk of self-harm. The patient is motivated to engage in treatment. The patient is likely to benefit from a combination of psychotherapy and medication. Recommendations / Agreed Action Plan: - Initiate Cognitive Behavioral Therapy (CBT). - Increase methylphenidate dosage. - Schedule follow-up appointment in 2 weeks. - Refer to educational psychologist for further assessment. Risk Assessment Formulation: Predisposing factors: Family history of mental illness, ADHD, and dyslexia. Precipitating factors: Academic pressure, bullying, and arguments with parents. Perpetuating factors: Social isolation, negative self-talk, and avoidance of schoolwork. Protective factors: Supportive family, previous positive coping strategies. My Staying Well Plan: My safety and wellbeing: I will contact my parents or therapist if I feel overwhelmed or have thoughts of harming myself. I will avoid situations that trigger my low mood, such as school. Signs I need additional support: Feeling sad most days, loss of interest in activities, difficulty sleeping, and thoughts of death. How I cope: I will talk to my parents, engage in activities I enjoy, and practice relaxation techniques. I can contact my therapist, my parents, or my friends. Giving support: I want my parents and therapist to help me manage my symptoms and support me. Staying well: I will engage in activities I enjoy, spend time with friends, and practice relaxation techniques. Mental Wellbeing Intervention Plans: Identified needs: Low mood, difficulty concentrating, academic difficulties, and social isolation. Interventions: CBT, medication management, educational support, and social skills training. Consent to Care: Patient and parents were informed about the CAMHS services and confidentiality. The care plan, risks of not engaging, benefits, and alternatives were discussed. About Me: My Story: I have been struggling with low mood, difficulty concentrating, and academic difficulties. I have always enjoyed playing video games and spending time with friends. I have a supportive family. My health and wellbeing, and how I want my life to change: I want to feel happier, improve my mood, and improve my concentration in school. What is important to me?: Spending time with friends, playing video games, and doing well in school. My individual needs: Support with my ADHD and dyslexia. Reasonable adjustments at school. My strengths: Supportive family, previous positive coping strategies, and a desire to improve. The views of my family, friends and people who are in my life: My parents are concerned about my mood and want me to get better. My friends are supportive and want me to feel better. Talking to Family and Friends about my health and wellbeing: I consent to my parents and therapist discussing my wellbeing.